Home and Community Program Care

Program Criteria

• Overview
  • Program Description
  • Program Requirements
  • Program Planning Guide
  • Program Linkages
  • Program Funding
• Program Description and Criteria
  • Principles and Objectives
  • Eligible Recipients
  • Funding Guidelines and Principles
  • Community Needs Assessment
  • Planning
    • Service Delivery
    • Training
    • Capital
  • Preparation Activities for Program Delivery
  • Regional Review Process
  • Program Evaluation and Reporting Requirements
  • Program Accountability
• Appendices
  • Appendix A - History and Background
    • Vision
    • Background
    • Home and Community Care - Building a Common Understanding
    • How Can the Home and Community Care Program Help First Nations and Inuit

Overview

Program Description

The First Nations and Inuit Home and Community Care Program will provide basic home and community care services that are:

• comprehensive
• culturally sensitive
• accessible
• effective
• equitable to that of other Canadians, and
• responsive to the unique health and social needs of First Nations and Inuit.

The Program will be delivered primarily by trained and certified personal care/home health aide workers¹ at the community level supported and supervised by registered nurses.

The Home and Community Care Program will be comprised of essential service elements and may be expanded to include supportive service elements provided the essential service elements are met. When communities already have all essential services through alternate sources, the program will not duplicate these services, but will allow communities to augment, through the supportive service components, the current services.

The Program will coordinate and link with existing programs and services at the community and/or provincial/territorial level.

¹ See Glossary of Terms for definition

Program Requirements

The First Nations and Inuit Home and Community Care Program initially will be driven by plans submitted by communities or by organizations on behalf of communities. This phase, commonly referred to as Program Planning, will ensure that a solid foundation for the Program is established.

The Program Planning phase will provide the opportunity for:

• community consultation about the home and community care needs of the community,
• community development and awareness,
• planning and delivery model development,
• staffing and training activities, and
• infrastructure and capacity development.

The community sets its own schedule for completing the program planning activities and decides how it will carry out the necessary work.

Once the community leadership has made the decision to proceed with Home and Community Care, the community should contact the region of its intent to start planning.

Note: For reasons of sustainability, specific regional processes for planning will be developed for communities with a population of 500 or less who are not affiliated with a Tribal Council or regional Inuit association. Please contact your region for further detail.

Program Planning Guide

1. Getting Started
2. Community Needs Assessment
3. Planning
   1. Service Delivery Plan
   2. Capital Plan
   3. Training Plan
4. Preparation Activities for Program Service Delivery
5. Program Service Delivery

Each community will address how it will provide basic home and community care services by undertaking a Community Needs Assessment to determine:

1. the home and community care service needs/priorities for the community,
2. the training needs required for the service priorities identified, and
3. capital needs.

Each community will then be required to prepare a Service Delivery Plan, a Training Plan, and a Capital Plan.

All plans will be reviewed by a review process established by the region for adherence to regional criteria, if established, complementing the national program criteria.

Once the plans have been approved, communities will develop a Workplan or Implementation Schedule outlining all the Preparation Activities for Program Service Delivery and the associated timelines. The workplan will serve as the principal document for entering into a contribution agreement with the funding agency.

The Evaluation Framework and Reporting Requirements for the Program will be developed by fiscal year 2000-2001. In the meantime, consideration of how the community will review and evaluate its Home and Community Care Program should begin during the development of the plans in the form of Community Evaluation Questions for the ongoing monitoring of the Program.

Program Linkages

The First Nations and Inuit Home and Community Care Program is one that builds onto existing investments in health and social community based services. Service Delivery Plans must demonstrate how the new program will build on and link with other related services and opportunities within and external to the community. An example of this would be the Health Canada Building Healthy Communities Home Nursing Program and the Department of Indian Affairs and Northern Development (DIAND) Adult Care Program (In-Home Component). The goal is for clients to have access to services in a manner that is holistic and comprehensive in its approach and maximizes resource utilization, both human and financial.

Program Funding

All funding for the First Nations and Inuit Home and Community Care Program will be allocated according to the Home and Community Care funding formula. Each community will be informed of its notional amount of ongoing funding before planning activities begin.

Funding for Planning

Communities wishing to undertake home and community care planning activities will be eligible for funding to support the planning activities. Contact your region to initiate this process.

Funding for Program Delivery

Communities who have already conducted all program planning activities, including the needs assessment and program service delivery plan will be able to use their portion of planning dollars to support program delivery activities or develop plans for expanding the continuum of services.

Funding for Training

The development of quality home and community care service delivery, staff qualifications and occupational health practices will require extensive training and upgrading in the majority of First Nations and Inuit communities. For this reason, a separate funding allocation has been identified within the overall Home and Community Care Program budget for training during the three year developmental period. Each region/territory will be required to develop a comprehensive training plan addressing the training needs of home care nurses, personal care workers and others who will be involved in the Home and Community Care Program. The plans will need to be developed in collaboration with First Nations, Inuit and other federal departments including DIAND and Human Resources Development Canada to enhance and maximize the efficient use of available training resources. All plans will be reviewed against established criteria.

Funding for Capital

Essential to the development and implementation of effective home and community care programs is the need to build a physical infrastructure to support program delivery. Capital requirements may include modifications to office space for staff or program delivery; staff accommodation may need to be obtained for more northern communities; medical equipment and supplies may be required to support the delivery of therapeutic programs, e.g. bath facility with hydraulic lift. For this reason, a separate funding allocation has been identified within the overall Home and Community Care Program budget for capital construction and capital equipment during the three year developmental period. Each region/territory will be required to develop a capital plan based on established criteria. The capital allocation is not intended to support renovations of homes or build institutions or health centres.

Program Description and Criteria

Principles and Objectives

The First Nations and Inuit Home and Community Care guiding principles and objectives have been developed to provide the basic fundamentals for the program. They are based on universally accepted home care precepts with adaptations for First Nations and Inuit cultural values. They have been designed so that Home and Community Care Programs will strive to achieve excellence and to ensure program quality and consistency. They are intended to contribute to program development and management throughout the life of the program. They should be a key resource that is reviewed for strategic planning and the development of policies and procedures. They are:

• Respect traditional and contemporary First Nations and Inuit approaches to healing and wellness.
• Planning will be community-based and community-paced.
• Programs will be available to individuals of all ages with an assessed need.
• Services provided will be at least equitable, effective and equivalent to those received by the general population and supported by quality assurance measures.
• Supportive to family and community involvement.

The objectives for the First Nations and Inuit Home and Community Care Program are:

• To build the capacity within First Nations and Inuit to develop and deliver comprehensive, culturally sensitive, accessible and effective home care services at a pace acceptable to the community.
• To assist First Nations and Inuit living with chronic and acute illness in maintaining optimum health, well-being and independence in their homes and communities.
• To facilitate the effective use of home care resources through a structured, culturally defined and sensitive assessment process to determine service needs of clients and the development of a care plan.
• To ensure that all clients with an assessed need for home care services have access to a comprehensive continuum of services within the community, where possible.
• To assist clients and their families in participating in the development and implementation of the client's care plan to the fullest extent and to utilize available community support services where available and appropriate in the care of clients.
• To build the capacity within First Nations and Inuit to deliver home care services through training, evolving technology, information systems to monitor care and services and to develop measurable objectives and indicators.

Eligible Recipients

The eligible recipients for this program are:

• First Nations and Inuit of any age; and
• Who live on a First Nations reserve, Inuit settlement or First Nations community North of 60; and
• Who have undergone a formal assessment of their continuing care service needs and have been assessed to require one or more of the essential services; and
• Who have access to services which can be provided with reasonable safety to the client and caregiver, within established standards, policies and regulations for service practice.
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Funding Guidelines and Principles

All program planning and service delivery funding will be allocated according to the Home and Community Care funding formula. This funding framework respects the resolution of the Assembly of First Nations (AFN) Annual General Assembly indicating the funding should be based on the health needs of First Nations. The funding formula model is based on delivery of essential service elements, a set of funding principles and care requirements.

The following principles provide the foundation for the funding allocation model:

• flexibility
• sustainability and longevity
• integration and linkages
• accountable
• accessible
• needs based
• plan based, and
• does not penalize First Nations and Inuit who currently have programs and services in place through other funding arrangements, nor will it duplicate existing programs such as DIAND's Adult Care Program (In-Home Component).

Allocation parameters of the funding formula include:

• on-reserve population, Inuit settlement, North of 60 First Nation communities
• care requirements of the population
• program support requirements
• program management and client assessment requirements
• operating and remoteness.

Community Needs Assessment

Each community will undertake a community needs assessment to identify:

1. the home and community care service needs and priorities,
2. training needs required for the service priorities identified, and
3. capital needs.

Assessing community needs involves surveying community members and health providers to find out which home and community care problems are most prevalent and need most attention. The community can then use this information and base line data to set its priorities in designing the Home and Community Care Program that will best meet its needs and to measure the impact of home care services for long term program planning and evaluation.

The community needs assessment is the key basis of the service delivery plan, training plan and capital plan. It will provide the foundation for all home and community care planning and as such must be completed carefully to ensure that it is representative of the community (appropriate sample size), addresses the real needs of community members (the right questions and most current data), addresses the essential services elements of the program, and involves proper and accurate analysis and summary (report).

For more information on carrying out the assessment, refer to Handbook 2 - Community Needs Assessment.

Planning

Service Delivery Plan

Each community will be required to prepare a service delivery plan describing how the program will be managed (management structure for the program), how the essential services will be delivered and how service and funding linkages will be made.

For more information on preparing a service delivery plan, refer to Handbook 3A - Service Delivery Plan.

Management Structure

This component of the service delivery plan includes:

• a brief description of the roles and responsibilities of the management structure;
• detailed work descriptions including roles, responsibilities, qualifications, experience required, and lines of supervision of all health services personnel to be involved in providing home and community care services;
• an organization chart showing the reporting requirements of each of the home and community care positions to the proposed management structure outlined above;
• the program policies to be implemented including policies on:
  • salary levels and benefits
  • professional registration and licensing
  • professional supervision
  • liability and malpractice insurance
  • confidentiality of medical records

Essential Service Elements

The Home and Community Care Program will be comprised of essential service elements. They may be expanded to include supportive service elements as long as the essential services are provided. The latter, however, is contingent on the availability of resources and identified needs determined in the program planning phase.

Where communities already have some or all essential services through alternate sources, the program will not duplicate these services. It will, however, allow communities to augment, through the supportive services components, the current services and "Reach For The Top" levels of home and community care.

The service delivery plan will identify how the essential service elements will be established. Essential service elements include:

• A structured client assessment process that includes on-going reassessment and determines client needs, family supports and service allocation. It is recommended that client assessments be performed by an appropriately trained registered nurse.
• A managed care process that incorporates case management, referrals and service linkages to existing services provided both on and off reserve/settlement.
• Home care nursing services that includes direct service delivery as well as supervision and teaching of personnel providing personal care services.
• The delivery of home support services that are determined by the community needs assessment plan and that do not duplicate, but enhance existing Department of Indian Affairs and Northern Development (DIAND) Adult Care Program In-Home services. Home support covers a range of services such as personal care services (e.g. assistance with Activities of Daily Living such as bathing, grooming, dressing, care of bed bound clients including turning, back rubs and routine skin care, etc.) and home management (e.g. light housekeeping, laundry, meal preparation).
• Provision of in-home respite care.
• Established linkages with other professional and social services that may include coordinated assessment processes, referral protocols and service links with such providers as hospitals, physicians, respite and therapeutic services.
• Provision of and access to specialized medical equipment, supplies and specialized pharmaceuticals to provide home and community care.
• A system of record keeping and data collection to carry out program monitoring, ongoing planning, reporting and evaluation activities.
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It is expected that the essential elements of the Home and Community Care Program will be developed initially in each First Nations and Inuit community. Based on community needs and priorities, the existing infrastructure and availability of resources, the Home and Community Care Program may expand to include supportive service elements. These supportive elements that may be provided within a continuum of home and community care might include but not be limited to:

• facilitation and linkages for rehabilitation and therapy services;
• institutional based respite care;
• adult day programs;
• meal programs;
• mental health home-based services for long-term psychiatric clients and clients experiencing mental or emotional illness. These services might include traditional counseling and healing services, medication monitoring;
• support services to maintain independent living which may include assistance with special transportation needs, grocery shopping, accessing specialized services and interpretative services;
• home-based palliative care;
• social services directly related to continuing care issues; and
• specialized health promotion, wellness and fitness.

First Nations and Inuit Home and Community Care will not:

• fund the construction and/or delivery of long term care
• institutional services; and
• will not duplicate funding for existing on reserve adult care services.

Service and Funding Linkages

The program model for the new First Nations and Inuit Home and Community Care Program is one that builds onto existing investments in health and social community based services. Service delivery plans will demonstrate how the new program will build on and link with other related services and opportunities provided within and external to the community. An example is the Home Nursing Program through Building Healthy Communities and the Department of Indian Affairs and Northern Development's Adult Care Program (In-Home Component). Other service and funding linkages may include community health nursing and the Non-Insured Health Benefits Program.

The goal is for clients to have access to services in a manner that is holistic and comprehensive in its approach and maximizes resource utilization, both human and financial. A structured client assessment, coordinated care and a case managed approach are just some of the tools that will assist communities in realizing more effective, appropriate and timely access to care. Each community or collation of communities will achieve this goal of seamless access over a period of time and in a manner that supports the delivery of the program as developed by the community(ies).

In addition, some provinces and territories have made investments to providing home care services on reserve and in Inuit settlements. It is important to incorporate these program supports in client assessment, case management and service delivery.

Training

Criteria and guidelines for the development of training plans refer to Handbook 3c - Training Plan.

Capital

Criteria and guidelines for the development of capital plans Handbook 3b - Capital Plan.

Preparation Activities for Program Delivery

Each community will be required to develop a Workplan or Implementation Schedule outlining all the preparation activities for program delivery. The workplan should set realistic timelines against which progress can be monitored.

During this developmental period, it is recognized that communities may be providing some service delivery but that the majority of time and resources will be on training and putting in place the necessary structures and processes to establishing a solid program foundation.

Regional Review Process

A collaborative review process will be established in every region and will play an important role to ensure that available resources are distributed according to the funding formula and that priority home and community care needs are treated on a priority basis. All plans will be assessed for eligibility, completeness and adherence to the national criteria outlined above.

Home and Community Care Service Delivery, Training and Capital Plans will be reviewed by regional review processes for:

• adherence to regional criteria, if established, complementing the national criteria;
• the presence of a program model that demonstrates the delivery of essential service elements, including the supportive service elements that may be introduced to the program;
• demonstration of coordination and/or linkages with existing and proposed home and community care programming and infrastructure such as adding components to existing services provided in the community in order to maximize outcomes;
• demonstration of economic feasibility and sustainability;
• demonstration that duplication of services will not occur;
• evidence of strong community involvement in the design, planning, operation and evaluation of all aspects of the program; and
• identification of capacity building requirements from a capital, human resource and management infrastructure development perspective.

As a result of the regional process, recommendations will be made:

• for the approval of the plans by the appropriate regional authority; or
• for revisions prior to reconsideration of the plans and approval by the appropriate regional authority.

Organizations will be able to appeal recommendations to the appropriate regional authority.

Program Evaluation and Reporting Requirements

The Evaluation Framework and Reporting Requirements for the program will be developed by the end of fiscal year 2000-2001.

Although the evaluation framework is not prepared, consideration of how the community will review and evaluate its Home and Community Care Program should begin during the planning phase in the form of Community Evaluation Questions to ensure community and regional evaluation questions are developed as part of the national framework. Communities will also need to identify data sources to collect and carry out the evaluation that responds to community questions, health outcomes, program value and effectiveness.

Communities will be required to develop information management processes. Data collection will most probably be paper based initially until development work occurs with a number of stakeholders and can build on the developments which have occurred around the First Nations Health Information System and the Regional Health Survey.

Program Accountability

The purpose of this section is to describe the accountability requirements for the program.

Accountability of the First Nations/Inuit Structure to its Members...

The structure is accountable to its members for the provision and management of the First Nations and Inuit Home and Community Care Program to achieve the objectives and outcomes established and mandated by its members.

The structure will ensure that it communicates to its members any changes which may arise as a result of or subsequent to their delivery of the First Nations and Inuit Home and Community Care Program.

The structure will ensure fair and equitable access to services for its members provided in a respectful manner. This will be supported by a formal process for assessing service delivery needs.

The structure will ensure that information concerning its members and the services they individually receive will be kept confidential in line with a code of ethics and privacy legislation related to health information.

The structure shall make available to its members an annual report on the management and delivery of the First Nations and Inuit Home and Community Care Program.

² For purposes of this document, First Nations/Inuit Structures are defined as: First Nations Band, Tribal Councils, First Nations/Inuit Health Authorities, First Nation/Inuit Service Delivery Organizations, First Nation Provincial/Territorial Organizations, Regional Inuit Associations.

The First Nation/Inuit Structure to the Minister of Health...

The structure will engage an independent auditor to perform a financial audit to examine the adequacy of financial controls and certify that sound accounting principles and practices are followed.

The structure will ensure that essential program elements and program standards are maintained.

The structure will uphold the First Nations and Inuit Home and Community Care Program principles and objectives.

The structure will collect and maintain data in accordance with the performance reporting requirements.

The structure will evaluate the First Nations and Inuit Home and Community Care Program to ensure effective management and delivery of the program.

The structure will provide the Minister with a copy of the annual report and the statistical information referred to in the reporting requirements.

The Minister of Health to the First Nation/Inuit Structure and its Members...

The Minister will respect the need for program planning and development to occur at a time and pace determined by First Nations and Inuit.

The Minister will ensure that the structure has an appropriate mandate to deliver the First Nations and Inuit Home and Community Care Program for its members.

The Minister will provide funding in accordance with the terms and conditions of agreements.

The Minister will evaluate the First Nations and Inuit Home and Community Care Program to ensure effective management and delivery of the program.

The Minister will uphold the First Nations and Inuit Home and Community Care Program principles and objectives.

The Minister will respect existing Treaty and Aboriginal rights and fiduciary relationships and negotiated self-government agreements.

The Minister of Health to Parliament...

The Minister will remain accountable to Parliament for the overall program.

The Minister will present an annual report on the program to Treasury Board.

Appendices

Appendix A - History and Background

Vision

First Nations and Inuit have a long tradition of caring for the health and well-being of their members within their families and communities. In the Health Canada report "National Consultation on Continuing Care Needs in First Nations Communities (1994:76)", prepared as part of the National Strategy for the Integration of Persons with Disabilities, the following summary on directions for continuing care programs in First Nations communities was provided:

First Nations and Inuit societies have different traditions and approaches to health and healing that must be respected. Aboriginal healing is a way of life rather than a segregated or specialized activity. These traditions, which emphasize the multi-dimensional nature of people as physical, mental, emotional and spiritual beings, must be recognized in addressing the continuing care needs of First Nations peoples. As Inuit and First Nations move toward self-government and jurisdiction over the development and delivery of health programs and services...the further development of health services, such as continuing care, which are managed and provided by First Nations and Inuit, is critical.

One statement of a First Nations vision for home care was put forward by Elders and persons living with disabilities and chronic illnesses in the Federation of Saskatchewan Indian Nations report "Home Care On Reserve: A Framework" (1990:7).

"The vision of the Elders, handicapped and chronically and acutely ill is to continue to live productive, useful lives in their homes, close to their families, in their communities...and (to) help maintain their culture, language and traditions...Their vision for home care on-reserve is a guarantee that (First) Nations will have the authority and finances to help them live and contribute always to their communities."

Background

The lack of home and community care in First Nations and Inuit communities has been recognized as an issue for over 15 years with a growing need for services being identified. The indicators of this need include:

• the burden of ill health in Aboriginal communities with disability rates twice the national average, 50% of respondents over 65 years of age in the First Nations and Inuit Regional Health Survey had arthritis/rheumatism and high blood pressure and approximately 30% were affected by diabetes, heart and lung conditions; injury rates three times the national rate, and 37% of those over 75 years need assistance with personal care and hygiene;
• demographic trends indicate that adult First Nations population will approximately double in the next 2 decades; and
• provincial health reform with the resulting changes in health care organization, closure of hospitals, introduction of early discharge programs, technological developments supporting home based therapies, and enhancement of community based programs.

These health status, demographic and health reform changes have meant that on-reserve a higher proportion of people at all ages are in need of home care, the cohort requiring home care services is increasing, and First Nations do not have the same access as other Canadians to re-investments in more complex and comprehensive home care services. Current programs and resources available to First Nations and Inuit cannot absorb the increased demands for home care services.

In response to this need, a joint Health Canada/DIAND/First Nations/Inuit Working Group was formed to develop a framework for a comprehensive home care program. This work has initially guided the development of the new Home and Community Care Program.

Throughout the summer of 1999, regional information sharing and feedback sessions were held with First Nations and Inuit in all provinces and territories. These sessions have further refined the program design, delivery, funding and accountability principles, and roles and responsibilities for the program.

Home and Community Care B Building a Common Understanding

A Home and Community Care Program is "a coordinated system of home and community health services which enables people to live in their home environment and to achieve their optimal functional ability and includes both health and social based services that are holistic in nature" (National Framework on Continuing Care Phase 1 B First Nations and Inuit Home Care).

The philosophy of care is to help people maintain their independence in the home. The home and community care vision recognizes that each person is different and unique and approaches their care in a holistic manner that looks at the person=s physical, social, spiritual and emotional needs. Home and community care is designed to support and enhance the care provided by family and community, but not to replace it. A foundational belief is that "Home Care must only do things for people that they cannot do for themselves in order to preserve their self-worth. When people feel good about themselves, they are more likely to be strong resources in their families and communities." (Paraphrase: Saskatchewan First Nations Home Care Program Guidelines, 1995).

Home and community care is more than housekeeping and homemaking services provided through the Department of Indian Affairs and Northern Development=s (DIAND) Adult Care Program (In-Home Component). Homemaking is just one of several services of a home care program linked through a coordinated assessment and managed care process. Other services of a home and community care program can include personal care, home nursing, and in-home respite care.

How Can the Home and Community Care Program Help First Nations and Inuit?

The First Nations and Inuit Home and Community Care Program aims to address the negative health effects experienced by First Nations and Inuit due to high rates of chronic and acute illnesses, disabilities and the changing health delivery mechanisms associated with provincial/territorial health reform. The First Nations and Inuit Home and Community Care Program can:

• assist First Nations and Inuit living with chronic and acute illness and disabilities in maintaining optimum health, well-being and independence while remaining in their homes and communities;
• ensure that all clients with an assessed need for home and community care services have access to a comprehensive continuum of services within the community, where possible;
• build the capacity within First Nations and Inuit to develop and deliver comprehensive, culturally sensitive, accessible and effective home and community care services; and
• home and community care will continuously seek new and innovative ways and means of responding to the identified needs in each First Nations and Inuit community.